Date :

Name:

Address:

City, State, & Zip:

Email Address:

Expiration Date and CVV2 #:____________________________________________________________________________(CVV2 number is a 3- or 4- digit number on the back of the card, right after the credit card number)

Add shipping here (if you forget, we'll add it for you.)_______________________________________(for U.S. retail orders under $25, shipping is $5.50; $25-50 is $6.95; $50-100 is $8.95; over $100 is $10.95. Other countries are higher -- please see ordering info page. Check/MO orders with insufficient shipping may be delayed.)

Add up for total (please figure very carefully) ____________________________________________

Please make checks/money orders payable to Lost Angeles Rubber Works.
Please allow 4-6 weeks for delivery in the U.S. (but we usually move faster than that!)
Any questions? Please see (you guessed it) the
ordering info page or email
larw@larubberworks.com.
Need more space? Just write on the back of this form.For help, please email
larw@larubberworks.com.